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Recent face picture with no hats or sunglasses

Please attach a photo of you and your EX *

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please no hats or sunglasses

First Name *

Last Name *

Email *

Cell: *

City *

State *

Gender: *

Date Of Birth: *

Hometown: *

Occupation: *

Social Media (Snapchat, IG, FB) *

Are you a legal US resident? If not list your residency status *

Tell us about yourself and your personality: *

How would your friends describe you? *

Full Name of your Ex: *

Ex’s Email *

Ex’s Cell/Home *

Ex’s Social Media (Snapchat, IG, FB) *

Ex’s age: *

Tell us about your Ex. *

How long ago did you break up? *

Tell us your breakup story, and why the relationship ended: *

What do you want to get out of being on the show? *

Do you ever want a Second Chance with your Ex? Tell us why: *

Have you or your Ex dated anyone else since the breakup? *

When was the last time you spoke with your Ex? How did it go. *

How did you hear about this casting? Include the name of the person who contacted you if possible! *

Have you ever appeared on TV before? If, yes, give date and network: *

Do you have any scheduling conflicts December 18' and/or Jan 19' we need to know about? If Yes, please list:

If cast, shoot is 1 day.

Optional: Record a quick video of you and tell us about yourself:

please no hats or sunglasses and make sure you are in good lighting

Have you ever been arrested, charged or convicted of a crime or violent offense (other than minor traffic violations)? *

YESNO

Have you ever had a temporary restraining order issued against you? *

YESNO

If yes to either of the last two questions, please give details (including dates)

RELEASES *

ELECTRONIC SIGNATURES. This application may be executed by original, facsimile or electronic signature. Any signed copy of this application delivered by facsimile or electronic transmission shall for all purposes be treated as if it had been delivered containing my original signature, and shall be binding upon me in the same manner as though an original signed copy had been delivered.

By signing below, I understand that it constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.
*